Misadventures With a Toothpick

Plus, a religious experience

BROBSON LUTZ M.D.

Once upon a time Ronald McElligott decided to build a bookcase. This was the beginning of a medical adventure that started with a piece of plywood in St. Landry Parish and ended with a hospitalization in New Orleans.

“I was moving a 4-by-8 sheet of 3/4-inch plywood. I dropped it on my left foot – not all that far a drop but just enough for a few expletives,” says McElligott, a retired DEA agent. He and his wife Carroll share five acres of bucolic Louisiana surrounded by sugar cane and soybean fields with 10 horses, a bunch of outside cats and eight mostly rescue dogs – the menagerie also previously included a now-deceased pet goat.

It is difficult to explain exactly where they live. Their mailing address is Bunkie in Avoyelles Parish even though they actually live in St. Landry Parish. They get their utilities from Washington Parish. The closest Walmart is in Opelousas about 17 miles away.

“Several days later, just before going to bed, I was hobbling around barefoot when I stepped on something sharp.

We have this long plush carpet in our bedroom. Drop something small and you have to hunt for at least 10 minutes to find it,” says McElligott, who checked his foot, saw the end of a toothpick, pulled it out and kept on hobbling on a now twice-wounded left foot.

The puncture wound from the toothpick healed quickly, but several days later he was still limping with intensified pain on the top of his foot where the plywood landed. He self-diagnosed his worsening symptoms to a bad bruise or maybe a hairline fracture of some bone in his foot.

McElligott then did what many rural Louisianans have done through the years: He came to New Orleans for medical help. He told a nurse friend that he had a had a foot problem, and the friend said, “You had better call Dr. Warren Bourgeois in New Orleans. He’s a good orthopedist.”

His appointment was on a Friday afternoon. Bourgeois took one look at McElligott’s painful, swollen foot and admitted him to the hospital. Pus was oozing through a small abscess draining from the top of his left foot.

With McElligott in the operating room later that Friday afternoon, Bourgeois sliced open the skin around the abscess on top of the foot and out popped a perfectly round piece of a toothpick just over half an inch long.

Bourgeois stuck a probe into the toothpick’s track which transversed the entire forefoot exiting from the bottom of the foot. This piece of toothpick had migrated from the bottom of the foot to the top stirring up all kinds of inflammation and infection along its course.

When Bourgeois told me about this case, I told him it sounded like a reportable case, medical lingo for an unusual enough happening to be published in a peer-reviewed medical journal. Medical literature since the 1800s is replete with case reports of swallowed toothpicks that migrate through various parts of the gastrointestinal tract, but this kind of toothpick injury was a new one for me.

Most swallowed foreign bodies, from single Mardi Gras beads to silver dimes, pass into the stomach, transverse the complete length of the small and large intestines and come out in a bowel movement with the ease of a commute from Covington to New Orleans on a clear day.

On the other hand, toothpicks are long, slender, rigid slivers of wood with sharp pointed ends. If a sharp tip pokes through the gastrointestinal tract and slips into normally sterile areas, trouble begins. Most case reports of swallowed toothpicks cite perforations occurring in the stomach or upper small bowel. Surgeons have even operated on patients with classic appendicitis only to find an unsuspected toothpick. Swallowed toothpicks have migrated to and penetrated into livers, hearts, kidneys, bladders, pancreases and even into and out of the major blood vessels ending up in places such as groins and thigh muscles.

The liver attracts most of these free-floating toothpicks where they cause all sort of abscess problems. The body’s immune system treats a toothpick like a bacterial invader with an outpouring of inflammation and pus. All this localized warfare can also secondarily attract bacteria using the foreign body as the focus to begin a full-scaled bacterial infection.

Physicians and other medical researchers often turn to MEDLINE when they want to search for treatment options of a particular disease or just to check on case reports of perhaps rare conditions. I searched “toothpick” and within seconds had a list of 211 medical article citations dating back to 1939 culled from 18 million articles in some 5,000 different medical journals.

My premise that McElligott’s foot injury by toothpick might be a medical first was shattered when I added the search term “foot” to “toothpick.” The medical literature contains at least nine separate case reports with toothpicks as the villain. Case reports going back decades had been published in various orthopedic, pediatric, podiatric and infectious disease journals.

A 1980 article in the American Journal of Surgery reviewed three case studies documenting the difficulty of diagnosing retained wooden toothpicks, because they don’t show up on usual X-rays used as radiopaque foreign bodies. Often, the person with the painful foot has no memory of even stepping on a toothpick. This is particularly true for persons with diabetes-induced decreased sensation in their feet.

Undiagnosed and retained foreign bodies are bacteria-attracting magnets. In McElligott’s situation the invading germ was a Staphylococcus aureus, the most common form of bacteria causing pus in skin and soft tissue infections. In other cases, the bacteria come from the mouth flora.

In a published report titled, “The Tale of a Toothpick,” a Georgia pediatrician described a 16-year-old girl barefoot in her kitchen. She stepped on a toothpick, pulled it out and went to an emergency room where X-rays were normal. The foot festered over the next two months and progressed to rip-roaring osteomyelitis. A culture grew Eikenella corrodens, a bacterium found in the human mouth. A minor scrape on the knuckle of a clenched fist inoculates the hand of the person who delivers the mouth blow with bacteria that are harmless in the mouth. A few days later the displaced bacteria progress into a raging hand infection, a true victim’s revenge.

The Georgia physicians were surprised to find this “corroding bacillus” causing a foot infection. A new X-ray showed bone changes diagnostic of osteomyelitis. Surgery was recommended to clean out the infected bone. A surprised surgeon found an unexpected piece of toothpick.

It is difficult to find a restaurant that cannot find a toothpick if asked, but point-of-grab toothpicks in dining establishments have been on the decline for years. Most modern diners, at least in the Western world, would agree on one piece of dining etiquette: you don’t use a toothpick in public no matter the aggravation of that miniscule bit of food trapped between two teeth.

Southern country men were often photographed with toothpicks until holding cigarettes became more chic. But I know of no Southern female who would ever succumb to tooth picking in public. Toothpicks have changed human families and lives as I can personally attest.

In the early 1950s when I was about four years old, my parents moved from New Jersey, my father’s home state, which never agreed with my mother’s lower Alabama/North Florida origins. One Sunday shortly after the move to Athens, Ala., they visited a local church whose denomination’s name in the South is frequently preceded with the word Southern. My mother filled out one of those cards you see in church pews for visitors and new folks in town.

The next week the preacher came a-calling with a toothpick in his mouth. My mother sat in the living room horrified for the entire 10 to 20 minute “visitation” until my misbehaving brother and I finally caused him to excuse himself. The next week my parents visited and subsequently joined the First Presbyterian Church on the courthouse square. And that’s how I became a Presbyterian. To this day I thank God in my prayers for toothpicks.